A day in the life of an NHS nurse - how our government is failing both patients and nurses

Last year 33,000 nurses left the NHS, 3,000 more than were recruited. There’s a simple solution - resisted by a government determined to press ahead with piecemeal privatisation.

If you take a look at
the average daily workload of an NHS nurse, you can see how it would drive any but
the most committed to leave the underpaid and undervalued profession.

Average staffing levels in NHS wards means
that there are 9 patients per nurse. In elderly care wards the average is 11
patients per nurse. The reality for nurses is it can be as much as 10 or 12
patients per nurse on a medical ward, and 14 to 16 patients per nurse on an
elderly ward. The National Institute of Clinical Excellent (NICE) and nursing
unions recommend no more than 8 patients per nurse, yet 40% of NHS nurses
reported to the Royal College of Nursing (RCN) that they are working with
ratios higher than this.

Imagine you're a nurse with a 12 hour shift.
It's meant to only be 11 hours work because you're meant to have a one hour
break (which you aren't paid for) but you'll probably end up working through
it. You have 10 patients who you have to help wash, give their medications
three times a day, and do a minimum of three sets of observations throughout
the day. You also have wound dressings to change for several of your patients,
and several need help toileting throughout the day. Some may be bed bound and
require full double handed care, requiring another nurse to help you.

You also need to speak to the medical team
for each of them to chase up their plans. Several need to be sent for scans,
and you need to speak to the porters and x-ray, CT or ultrasound and get them
sent down. Dementia patients or those who are falls risk can require an escort
so you have to find someone to go with them.

If you're on a surgical ward you will have a
couple of patients on Patient Controlled Analgesia, or epidurals needing hourly
monitoring, as well as observations hourly for those returning from theatre, hourly
sliding scales for diabetes patients, Naso-Gastric or Total Parenteral
Nutrition feeds needing checking and monitoring. Alongside that you’re trying
to safely take multiple patients to theatres and radiology which means being
off ward for ages, while somehow simultaneously closely monitoring the patients
you've left behind.

Desperately trying to free up beds

On top of that you will be managing multiple
discharges to get patients home to free up beds for the next day’s intake of
patients awaiting surgery, and chasing pharmacy for medications. There is
barely any time to carry out the essential work of teaching patients about
managing new stomas or controlling their diabetes or any of the other essential
parts of patient education which are left in the hands of overstretched nursing
staff.

God forbid any of the patients become acutely
unwell. Then you have to drop everything and spend 2-3 hours managing them
intensively, calling the medical or surgical team, the clinical response team,
maybe the crash team if they suffer a peri-arrest. Performing observations
every 15-30 minutes, administering IVs, taking bloods, deciding whether to
inform the next of kin if it's a serious deterioration or if they are elderly
or at the end of life. If you eventually stabilise them you have to go back and
catch up on your work for your other 9 patients, who you haven't been able to
do anything for in the meantime.

A study in Australia found that on a busy
ward, nurses were making roughly 200 decisions every hour regarding their work.
You spend all day every day running from task to task, with barely any time to
think.

Documenting everything – even when it was
done badly

On top of all this you have to find time to
document everything about those ten patients; those three sets of observations
(as a minimum, more if they become acutely ill), at least one detailed nursing
care plan and a follow up note at the end of the shift, noting every time
someone was repositioned, every bowel movement, every aspect of personal care,
wound care, important conversations you had with the medical team, with
patients, their relatives or social services.

There aren't enough staff to do all the work,
but the hospital still requires you to document everything you did to prove you
did if (even though it was probably done badly or in a hurry, or maybe not at
all).

If there were enough staff to do all the work,
this level of documentation wouldn't be necessary. With inadequate levels of
staffing, it just become an onerous imposition, and saps what little spare time
you have.

By the end of your shift if you work flat
out, skip your breaks, cut a few corners and don't spend too much time doing
any of the niceties for patients (the little chats, extra cups of tea,
comforting them if they've had bad news, and so on) you might have just about
managed to do all your care and provided decent, if a little basic care for your
patients.

If you have managed to squeeze in most of
your documentation you might only leave 30-40 minutes late as you tidy up the
last bits of paperwork, check you've done all your notes, updated all the care
plans, fluid balances, stool charts, repositioning charts and the rest. But if
someone became really unwell and you spent 2-3 hours nursing them intensively,
you'll probably be staying behind an hour or two to finish notes, as the only
time you've really got to work on them is when the next shift has arrived and
they can take over all your responsibilities.

How the ‘market’ intensifies nurses workloads

The effects of years of austerity on hospital
budgets, combined with the market mechanisms which allocate NHS funding, are
also driving the workload up for nurses. Hospitals receive a payment (a tariff)
per patient admission. Hospitals facing budget restrictions and reductions in
bed numbers are utilising medical and surgical advancements to improve patient
care, but also to minimise time as inpatients. This is done to maximise through
flow of patients so they can receive as many tariff payments and maximise their
income at times of budget restrictions. They do this so they can afford to pay
staff and continue to maintain services, but it drives up nurses workload to an
unprecedented level. Whereas 15-20 years ago patients would stay on wards for
weeks at a time till they were full recovered, now it’s common for patients to
be discharged home as soon as they are stable and not acutely unwell, the
remainder of their care being carried out in the community.

Whereas a nurse used to have a mix of acutely
unwell patients, and stable recovering patients requiring minimal care, now
every patient a nurse cares for is likely to be acutely unwell, meaning their
care needs and the workload for the nurse is at maximum every shift. Such a
situation creates a horrendous work environment where nurses work flat out all
the time, with no downtime or quiet days. It accelerates burnout, and means
newly qualified nurses trying to find their feet and develop their skills and
resilience are subject to unimaginable pressures and levels of responsibility
that they would not have faced 10-15 years ago.

This is why nurses are
leaving, and until it changes, they won't stop leaving.

The simple solution

The only way to improve
retention and begin to reverse the outflow of nurses from the NHS is to reduce
their workloads to a safe, manageable level. This means more nursing staff on
wards and in community services.

There is a remarkably
simple policy solution to this which has worked well in other countries;
mandatory minimum safe staffing levels, enforced in law. This has been
implemented in both Australia and California, in response to concerted protests
by nurses and their unions.

There is a consensus for
this across nursing unions and the nursing workforce. The RCN, UNISON and Unite
all call for mandatory minimum safe staffing levels across NHS wards, and
surveys of nurses show 90% in favour.

What is stopping the
government adoption of this policy is the impediment it would pose to cutting
and privatising the NHS, and the demand it would create for increased funding
to pay for the staffing. But it is absolutely necessary if we are going to see
the continued functioning of the NHS, and the survival of nursing as a viable
profession. For this reason all nurses and their unions have to become more
active and aggressive in campaigning on this issue, for the wellbeing of
ourselves, our patients and the NHS.

About the author

Mark Boothroyd is a staff nurse at Guy's and St Thomas NHS Foundation
Trust. He is a Unite member and campaigner for safe staffing in the NHS.

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